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2�:C15ION ENVIRO-TECH CHAIN OF CUSTODY <br /> AND ANALYSIS REQ UEST DOCUMENT <br /> REPORTCLIENT INFORMATION <br /> DETAILS Rush Analysis: 5 Days 2 Days 24hrs <br /> Client: �-P o nc/S /"�/�we Sampler(s): <br /> Subject to surcharge <br /> Customer Number: S i Fly Comp Sampler Set Up Date:— Time: QA/QC report required: yes no <br /> Address: �vy Time: Mileage: If yes,To: State Client Other <br /> C-4 9 S Lab number: / <br /> Phone: %G' -- �� / — ca <br /> FAX: a s m o z o x <br /> U f° A c <br /> Project name: 3 N <br /> FQ �♦ <br /> o � <br /> Contact person: l>5 �t/= _Em ° _ W <br /> a " z ,�v, z CTI <br /> r V v v a <br /> SAMPLE • TION o a m x o <br /> SampleDate Time d a w 3 m x a3 <br /> Number Location Description Sample Sample z a 3 a" a U <br /> 1zL zG a 6-L tu <br /> CUSTODY <br /> `�_�jU ' <br /> Relinquished y' Fate me eived bp: to e <br /> Relinquished by: ate Time Received by: ate.Time <br /> Time <br /> 7771 Relinquished by: Date Time Received by: Date Time <br /> PRECISION ENVIRO-TECH 7743 N. West Lane, Suite B2 * Stockton CA 95210 * Telephone(209)477-8105 * FAX: (209)477-8148 <br />